Ontario Patient Consent Form

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					                                                        PATIENT CONSENT FORM
 COLLEGE OF           I,
H O M E O P A T H I C ____________________________________________________________________________
   MEDICINE           of the following address:
                      consent to treatment by the practitioners of the Ontario College of Homeopathic Medicine. I
                      understand that this is a teaching clinic and that my case will be taken by student practitioners
                      who are supervised at all times by a qualified Homeopathic Doctor. I understand that other stu-
                      dents may be present during my case taking for observation purposes only.
                      □ I understand that my case may be videotaped for OCHM teaching purposes only.
                      I confirm that there has been no suggestion made to me by the Ontario College of Homeopathic
                      Medicine, or by anyone under its direction or control to prevent me from seeking or following

                      allopathic treatment. The decision to seek homeopathic treatment is solely my decision and I
                      understand that I may still seek the treatment of an allopathic doctor or any other health practi-

                        I understand the cost of treatment and agree to pay my account according to the guidelines set
                        by the Ontario College of Homeopathic Medicine (all fees are non-refundable).
                        All information disclosed is confidential and remains within the premises of
                        Ontario College of Homeopathic Medicine.

                        Dated and signed this ___________(day) of __________________month ____________(year)

                        Signature_______________________________ Witness______________________________

                                         COST OF TREATMENT (effective from February 1st /2010)
                                                       (please check one)

                        For the 1st time patients (adults & children):

                                □ Option 1:             $120.00 initial consultation + 3 follow-up visits
                                                                 (payable in advance)
                                □ Option 2:             $50.00 initial consultation &
                                                        $35.00 each follow-up visit
                                                        $20.00 for every telephone consultation
                        Special family rate:
                        For the second child and all other children under the age of 18, the cost is
                                                       $80.00 for 4 visits payable in advance
                        Senior & student rate          $80.00 for 4 visits payable in advance

                                                           PRICE FOR REMEDIES
                        Regular remedies are charged $5.00 per remedy. Postage is charged extra when a remedy is mailed
                        to a patient. Rare and special order remedies are charged extra depending on cost and shipment
                        charges, and patients will be promptly notified.
                        24-hour notice is required for cancellations, late cancellation fee may apply. In case of emergency
                        cancellations after hours please call 416-535-5995/ext 6 or e-mail a cancellation notice to

   332 Dupont Street
                         The OCHM Teaching Clinic is open to patients for emergency situations on
                                   Mondays & Tuesdays from 9:00 am to 5:00 pm
 Toronto ON M5R 1V9               Wednesdays & Thursdays from 9:00 am to 8:00 pm
                         We are unable to provide emergency services after these hours and strongly recommend that you
   Tel: 416-535-5995

                        Payment are accepted in cash, by cheque, debit, Visa, MasterCard & AmEx.

Description: Ontario Patient Consent Form document sample